MACRA Payment: APM vs. MIPS

MACRA Payment: APM vs. MIPS

Comparison of Alternative Payment Models and the Merit-based Incentive Payment System

 Merit-based Incentive Payment SystemAlternative Payment Models
EligibilityMerit-based Incentive Payment System:

Eligible professionals for 2019 and 2020 include: physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists (STAT. 93)

 

After 2020, it is anticipated that most eligible professionals who are currently participating in Medicare fee-for-service payments will be part of the MIPS track. (STAT. 93)

 

In an individual program year, new Medicare eligible professionals in their first year of enrollment are excluded.

(STAT. 95)

 

Participant must meet a volume threshold of a minimum number of one or more of the following: Medicare beneficiaries, items/services, and/or allowable charges; OR have submitted Medicare Part B reimbursement for more than one year.

(STAT. 94)

Alternative Payment Models:

A qualified APM is any one of the following:

  • A Medicare Shared Savings Program Accountable Care Organization;
  • A model expanded under the Center for Medicare & Medicaid Innovation (CMMI) that is not a Health Care Innovation Award recipient;
  • Medicare Health Care Quality Demonstration Program or Medicare Acute Care Episode Demonstration Program; or
  • A demonstration program required by federal law.

(STAT. 121)

 

Where the practice:

  • Uses quality measures comparable to measures under MIPS;
  • Uses a certified electronic health record;
  • Assumes more than a “nominal financial risk” OR is a medical home expanded under the CMMI.

(STAT. 118-120)

 

A qualifying participant must meet a volume threshold of Medicare payments or beneficiaries paid through the alternative payment model.

(STAT. 118-120)

Incentives and PenaltiesMerit-based Incentive Payment System:

Payment adjustments are determined by the combined weighted score of quality, resource use, meaningful use, and clinical practice improvement activities. Baseline payment adjustments for the following years include:

  • 2019: +/- 4%
  • 2020: +/- 5%
  • 2021: +/- 7%
  • 2022: +/- 9%

 

2019 through 2024: Exceptional performers may be eligible for an additional positive payment adjustment.

 

2026 (and beyond): 0.25% annual baseline payment update.

(STAT. 91-92/102-103/106-107)

Alternative Payment Models:

2019 through 2024: 5% annual lump-sum bonuses.

 

Transition into payment with more risk.

 

2026 (and beyond): 0.75% annual baseline payment update.

(STAT. 117-118)

APMs = alternative payment models; CMMI = Center for Medicare & Medicaid Innovation; MIPS = Merit-Based Incentive Payment System